503.4F PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF PRESCRIPTION MEDICATION TO STUDENTS

 
PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION
OF PRESCRIPTION MEDICATION TO STUDENTS
 
_______________________________   _________     ____________    ___/___/___
Student’s Name (Last), (First), (Middle)   Birthday         School                  Date
 
School medications and health services are administered following these guidelines:
  • Parent has provided a signed, dated authorization to administer medication and/or provide the health service.
  • The medication is in the original, labeled container as dispenses or the manufacturer’s labeled container.
  • The medication label contains the student’s name, name of the medication, directions for use, and date.
  • Authorization is renewed annually and immediately when the parent notifies the school that changes are necessary.
 
___________________________  ____________   _____________   ____________
Medication/Health Care                    Dosage             Route                   Time at School
 
______________________________________________________________________
 
______________________________________________________________________
Administration Instructions
 
______________________________________________________________________
 
______________________________________________________________________
Special Directives, Signs to Observe and Side Effects
 
______/______/_______
Discontinue/Re-Evaluate/Follow-up Date
 
________________________________________________ ______/______/______
Prescriber’s Signature Date
 
________________________________________________  ___________________
Prescriber’s Address                                 Emergency Phone
 
I request the above named student carry medication at school and school activities, according to the prescription, and a written record kept. Special considerations are noted above. The information is confidential except as provided to the Family Education Rights and Privacy Act (FERPA). I agree to coordinate and work with school personnel and prescriber when questions arise. I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.
 
__________________________________________________ ______/______/______
Parent’s Signature                                                                       Date
 
_________________________________________________ ____________________
Parent’s Address                                                                        Home Phone
 
_________________________________________________ ____________________
Additional Information                                                                Business Phone
______________________________________________________________________
 
______________________________________________________________________
 
 
*Adopted:  12/13/10
*Revised:  11/12/12
*Reviewed: 09/18/17
*Reviewed: 09/12/22
Uploaded Files: 
PDF icon 503.4F Parental Authorization and Release form for the Administration of Prescription Medication to Students.pdf